Provider Demographics
NPI:1285266304
Name:JOHNSON, TYRIUS URIAN I
Entity type:Individual
Prefix:
First Name:TYRIUS
Middle Name:URIAN
Last Name:JOHNSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-6235
Mailing Address - Country:US
Mailing Address - Phone:405-887-7933
Mailing Address - Fax:
Practice Address - Street 1:512 N PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-6235
Practice Address - Country:US
Practice Address - Phone:405-887-7933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN083753860171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1234567891OtherN/A